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4 integrative technological approaches to pain

From low-level light therapy to hyperbaric oxygen therapy, technological advances in pain management for animal patients are a boon to veterinary practice.

Today’s veterinary technology offers unique opportunities for enhancing pain management protocols, and forming comprehensive multimodal approaches to pain. Clients are increasingly concerned about the immediate and long-term effects of pharmaceutical medications – these concerns, sometimes founded (or unfounded) by “Dr. Google” have led to an increased pursuit of therapies traditionally labeled as complementary or alternative. As a modern veterinarian, you can improve patient care plans and client trust by becoming familiar with and using these tools.  In this article, we will provide a brief overview of several of the most commonly used integrative pain management tools in veterinary medicine today.

1. Low-level light (LLT) therapy/ laser therapy/ photobiomodulation

The word “laser” stands for “light amplification by stimulated emission of radiation”. Therapeutic laser therapy has been established for decades in the human field.  Veterinarians should be cognizant of the difference between a veterinary therapeutic laser and a light emitting diode (LED), which can easily be purchased online at a relatively low cost. LEDs utilize a broader range of wavelengths; therapeutic laser therapy typically utilizes wavelengths in the 600 nm to 1070 nm range, which allows for deeper tissue penetration.1

Veterinary therapeutic laser therapy units (typically Class 3-4 lasers) can vary in a number of ways, including wavelength, power density, pulse structure and even polarization.1  Additional parameters can include options or exact settings for exotic animals versus small animals versus large animals.

This modality is unique in that veterinary technicians can easily perform the therapy by utilizing preset therapeutic settings – these settings may include such labels as “intervertebral disc disease”, “wound” or “chronic inflammation”. The average time for a complete laser therapy session will depend on the number of points utilized, as well as the strength of the laser to deliver “x” number of Joules per time unit – the average time can range from about four to 15 minutes total.

Treatment indications

 This modality can be utilized for several purposes, including but not limited to:1

  1. Wound healing – including chronic or acute skin conditions or post-operative incision sites
  2. Decreasing pain and inflammation
  3. Spinal cord or neurological injury2
  4. Post-dental cleanings and procedures
  5. Preventative maintenance against sports-related injuries for agility dogs.

Evidence for pain reduction has been demonstrated in several studies, including one in which laser-treated post-operative tibial plateau leveling osteotomy (TPLO) patients demonstrated greater healing and significantly improved peak vertical force analysis versus their untreated counterparts.3 Significant gait improvements were noted in another study that compared laser treated post-operative TPLO patients versus untreated.4 Human literature has also noted a reduction in the pain associated with knee osteoarthritis following treatment with high-intensity laser therapy. 5

How it works

 LLT functions in several ways, including:

  • Increasing adenosine triphosphate (ATP) production1
  • Altering reactive oxygen species1
  • Modulating level of cytokines1
  • Stimulating the immune system1
  • Stimulating neurogenesis1

More information

 The North American Association for Photobiomodulation Therapy (NAALT) offers you the opportunity to remain up to date on the latest research and more. Examples of companies that offer a variety of laser therapies are Companion, Cutting Edge and Respond.

From left to right: Baxter enjoys laser therapy during his acupuncture session for herniated disc treatment; Roxy receives laser therapy as part of a conservative management protocol for her partial cranial cruciate ligament rupture; Recently diagnosed with thoracolumbar disc herniation, Snuggle is given Assisi Loop treatment during his laser therapy.

2. Regenerative medicine/ stem cell therapy

Regenerative medicine involves the harvesting and utilization of the body’s cells in order to treat diseases. Results have been controversial. This author will examine one main subset of regenerative veterinary medicine – stem cell therapy. Other therapies in this arena may include “platelet rich plasma” (PRP) or platelet injections, or “plasma rich in growth factors” (PRGF) injections.

Advanced veterinary training and an intimate knowledge of anatomy is necessary for the utilization of this technology. This procedure should be performed by veterinary professionals.

Treatment indications

In order to protect the patient’s retina and ocular health, laser goggles (coined “Doggles”) are placed on the head during treatment.

 In small animal medicine, stem cell therapy is typically utilized for orthopedic conditions, such as osteoarthritis or cartilage degradation in long bone joints. In a 2018 study examining over 200 stem cell-treated canine patients, 90% of dogs demonstrated marked improvement in mobility, and daily activity.6 However, it is interesting to note that the use of regenerative medicine has not been limited to degenerative orthopedic conditions.  A recent 2019 study analyzing the use of mesenchymal stem cells to treat keratoconjunctivitis sicca (KCS) demonstrated a significant decrease in expression levels of such inflammatory markers as CD4, IL-6, IL-1 and more.7

How it works

Mesenchymal stem cells (MSC) can be utilized for cartilage regeneration in animals.8,9 These cells are specifically selected due to their ability to take on the specific “morphophysiological aspects” of the cells around them, or overall plasticity.10 Cartilage regeneration is thought to be produced via:8

  1. Recruitment of endogenous cells
  2. Differentiation into chondrocytes
  3. Secretion of trophic factors for chondroprotection and immunosuppression.

Interestingly, the harvesting of mesenchymal stem cells can be performed at a myriad of locations in the small animal, including but not limited to the umbilical cord, muscle, fat pads, synovial fluid, adipose tissue and bone marrow.8 Following selection and harvesting of the cells, they are typically transplanted intra-articularly.9 Within the equine world, stem cell therapy studies have demonstrated improvements following injections into tendons and ligaments.11,12

More information

 The North American Veterinary Regenerative Medicine Association (navrma.org) offers readers the latest research and developments of this tool.

3. Pulsed electromagnetic field (PEMF) therapy

This is a form of electrotherapy that utilizes electromagnetic waveforms to treat tissues.13 PEMF therapy can differ in a number of ways – including but not limited to the strength of magnetic fields (measured in units of Gauss), pulse width and pulse frequency, as well as targeted or non-targeted devices.13

Targeted PEMF therapy devices can be sold directly to veterinary clients. This can empower them with the ability to treat their pets from home.

Treatment indication

 PEMF can be utilized for conditions such as edema, bone healing, wound healing, acute and chronic pain, as well as osteoarthritis and general inflammatory conditions.13 Interestingly, this is one modality that has been approved by the FDA to treat conditions like post-operative pain as well as non-union fractures.13 In human medicine, this modality can be covered under Medicare and Medicaid.

Research demonstrating effective pain control with this therapy abounds in today’s literature. One study demonstrated superior pain control in osteoarthritic dogs using a non-targeted PEMF device, as compared to treatment with Firocoxib (a non-steroidal anti-inflammatory).14 Given this result, it is not surprising that PEMF devices have been advertised as “non-pharmaceutical anti-inflammatory devices or “NPAIDs”.13 Significant pain control with PEMF therapy has also been established in human literature; daily targeted PEMF treatment of human subjects following breast surgery resulted in significant pain reduction and reduced use of pharmaceutical pain medications.15

 

How it works

 Targeted PEMF influences the nitric oxide (NO) molecules within the body, leading to reduced levels in inflammation. Other researched methods of action include the increased presence of heat shock proteins, affected cell membrane adenosine receptor expression, and more.13

More information

This author would advise veterinarians to be diligent in utilizing PEMF devices that demonstrate research-based evidence in the veterinary field, since a plethora of PEMF and PEMF-like devices can be found online. More information on this category of products can be found at Respond Systems (respondsystems.com) as well as Assisi Animal Health (assisianimalhealth.com).

 

 4. Hyperbaric oxygen therapy (HBOT) 

Hyperbaric oxygen therapy involves breathing 100% oxygen under the presence of increased atmospheric pressure.16 Literature on this modality can be found in both human and veterinary journals. Unlike the previously mentioned modalities, HBOT requires significant financial investment and safety precautions in order to avoid explosions, given the high concentrations of oxygen required.17

 Treatment indications

 HBOT is typically practiced as an adjunctive therapy.  Conditions that can be addressed with this therapy include but are not limited to:16

  • Wound healing16
  • Carbon monoxide poisoning16
  • Severe inflammation cases – such as sepsis, snake envenomation, ischemia, encephalitis and more18

How it works

Above: Penny receives cerebral treatment with Assisi Loop for her cerebellar abiotrophy condition; Turner (right) loves his bi-weekly treatments with Assisi Loop for cervical disc herniation.

 Hyperbaric oxygen therapy targets molecular mediators of inflammation, including cytokines, nitric oxide (NO) and growth factors.16 This leads to decreased edema and stimulation of angiogenesis, as well as recruitment of macrophages and more.16 These mechanisms of action can be especially groundbreaking in any clinical arena of decreased or lowered oxygenation within the body. For example, one study demonstrated that HBOT improved neurological outcomes following cardiac arrest and resuscitation.19

 More information  

Additional research articles and information can be found at the Veterinary Hyperbaric Medicine Society website (vhbot.org).

 Conclusion

Modern veterinary technology offers a range of opportunities for multimodal pain management plans. Both human and veterinary literature has provided research-based evidence for the technologies discussed in this article. However, more research is necessary to elevate and understand the strength and reach of these therapies.

* this article was peer reviewed

References

1Chung, H, et al. “The Nuts and Bolts of Low-level Laser (Light) Therapy.” Ann Biomed Eng. Vol. 40. (2)2012.

2Draper, WE, et al. “Low-level laser therapy reduces time to ambulation in dogs after hemilaminectomy: a preliminary study.”  Journal of Small Animal Practice. Vol. 53. 2012.

3Rogatko, CP, et al. “Preoperative low level laser therapy in dogs undergoing tibial plateau levelling osteotomy: a blinded, prospective, randomized clinical trial.”  Vet Comp Orthop Traumatol, 30 (1): 46-53.

4Renwick, SM, et al. “Influence of class IV laser therapy on the outcomes of tibial plateau leveling osteotomy in dogs.”  47 (4): 5050 – 515.  Vet Surg. 2018.

5Wyszynska, J, et al. “Efficacy of high intensity laser therapy in treating knee osteoarthritis: a first systematic review.”  Photomedicine and Laser Surgery, Vol 36 (7). 2018.

6Shah, K, et al. “Outcome of allogeneic adult stem cell therapy in dogs suffering from osteoarthritis and other joint defects.”  Stem Cells International Volume. 2018.

7Sgrignoli, MR, et al. “Reduction in the inflammatory markers CD4, IL1, IL-6, and TNFalpha in dogs with keratoconjunctivitis sicca treated topically with mesenchymal stem cells.”  Vol 31 (39), 101-525. 2019.

8Sasaki A, et al.  “Mesenchymal stem cells for cartilage regeneration in dogs.”  World Journal of Stem Cells, 26 11 (5): 254-269.  2019

9Kriston-Pal, E, et al. “Characterization and therapeutic application of canine adipose mesenchymal stem cells to treat elbow osteoarthritis.” Canadian Journal of Veterinary Research. 81 (1): 73-78. 2017.

10Markoski, MM. “Advances in the Use of Stem Cells in Veterinary Medicine: From Basic Research to Clinical Practice.”  Scientifica. 2016.

11Godwin, EE, et al. “Implantation of bone marrow-derived mesenchymal stem cells demonstrates improved outcome in horses with overstrain injury of the superficial digital flexor tendon.” Equine Vet J.  44(1):25-32.  2012.

12Beerts, C. et al. “Tenogenically induced allogeneic peripheral blood mesenchymal stem cells in allogeneic platelet-rich plasma: 2-year follow-up after tendon or ligament treatment in horses.” Front Vet Sci. (4) 158. 2017.

13Gaynor, JS, et al. “Veterinary applications of pulsed electromagnetic field therapy.” Research in Veterinary Science. Vol 119 1-8. 2018.

14Pinna, S, et al. “The effects of pulsed electromagnetic field in the treatment of osteoarthritis in dogs: clinical study.” Pakistan Veterinary Journal, Vol 33 (1): 96-100. 2012.

15Rawe, A, et al. “Control of postoperative pain with a wearable continuously operating pulsed radiofrequency energy device: a preliminary study.” Aesthetic Plastic Surgery,  36: 458-463. 2012.

16Al-Waili, NS et al.  “Effects of hyperbaric oxygen on inflammatory response to wound and trauma: possible mechanism of action.”  The Scientific World Journal 6, 435-441. 2006.

17Hochman, L, et al.  “Veterinary hyperbaric oxygen therapy: a critical appraisal.” Plumbs therapeutic Brief. 2017.

18Braswell, C, et al. “Hyperbaric oxygen therapy.”  Compendium: continuing education for Veterinarians. 2012.

19Rosenthal, R, et al.  Hyperbaric oxygen reduces neuronal death and improves neurological outcome after canine cardiac arrest.  Stroke, Vol 34 (5): 1311-1316. 2003.

 

Scientists reveal new theory on hoof disease

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Through the use of 3D imaging, the University of Nottingham has uncovered about the cause and future treatment of hoof disease.

Using innovative 3D Synchrotron imaging techniques, as well as histological sampling and stem cell biology, scientists at the University of Nottingham have discovered new information about the causes and potential treatment of hoof diseases in horses. The research team studied the hooves of 129 horses, acquiring the most detailed pictures ever produced of hoof structure, biology and physical dynamics.

Photo courtesy of University of Nottingham
New high resolution imaging techniques allow scientists to dissect the hoof components and visualise them in 3D

The results revealed a number of key findings:

  • A “dished hoof” (i.e. a dorsally curved hoof as observed in cases of chronic laminitis) is fundamentally caused by the fact that hooves are asymmetric (with a short heel and long toe). This in turn explains why donkeys are less prone to hoof disease/deformities/pathologies, since they tend to have long heels.
  • The dorsal curvature can be exacerbated by a low body condition score or/and rapidly-growing hoof.

The research, led by Dr. Cyril Rauch, Associate Professor in Physical and Mathematical Veterinary Medicine & Science, will have huge implications for the prevention and management of chronic hoof pathologies and deformities.

royalsocietypublishing.org/doi/10.1098/rsif.2019.0214

Essential oil use for professional self care

Essential oil uses for self care is a time-honored modality for healing our patients that can also be utilized to heal ourselves.

Too often, I read of a veterinary colleague who has taken his or her own life. It’s always such tragic news — one that leaves your soul heavy and your heart broken for those left wondering “why?” I have also experienced many forms of burn-out and emotional hardship. While I feel I am a resilient person, there are times when I just want to throw in the towel and walk away. This is life. This is normal. During such times, I use my self care modality of choice — Veterinary Aromatic Medicine, the use of essential oils for physical and mental well-being — to give me extra emotional support.

As veterinarians, in an occupation that can be quite stressful, I feel it’s important that we engage in regular self care routines to help us cope with our day-to-day struggles. Meditation, Reiki, grounding practices, yoga, prayer, getting a massage —all these options are wonderful for our self care — and all can be made even better with the use of essential oils. No matter which method you choose to relieve your stress, I urge you to always strive to include some essential oils in your practices. I can guarantee you will find them quite synergistic.

There are many essential oils, and every one of them will carry some sort of emotional effect. I will list some of my favorites in this article, but realize that any essential oil can become quite important in your own life, regardless of what anyone tells you its property is “supposed to be”. Trust yourself. If the scent r feel of an oil calls to you and makes you feel better — go with it. You know yourself better than any book or report on supposed effects.

Essential oils for emotional support

  • Black Spruce (Picea mariana) is rich in spiritual connection. It can help release emotional blocks, and is balancing and grounding.
  • Melissa (Melissa officinalis) is indicated for depression, grief and anxiety.
  • Cedarwood (Cedrus atlantica) is reported to aid in a full night’s sleep, and to help with stress and anxiety. Note: Several species fall under the name “Cedarwood”.
  • Roman Chamomile (Anthemis nobilis) can support bravery, strength and reduce anxiety.
  • Frankincense (Boswellia carterii) is one of the more recognized essential oils and is often used with meditation and prayer to help release the past, move through transitions, increase life force, and for depression and anxiety.
  • Ylang Ylang (Cananga odorata) is very balancing, and is indicated for low self esteem, to filter out negative energy, increase thought focus, and restore confidence and peace.
  • Bergamot (Citrus bergamia) is well recognized in the aromatherapy community and has been indicated to reduce insecurity, aid with depression and anxiety, and help release negative emotions.

Essential oils effectively relieve stress and anxiety

Crossed wrist position for essential oil grounding exercise.

I have always been impressed by the power of essential oils to not only improve my patients’ physical well-being, but to support their emotional states as well. These benefits are not limited to our animal patients. Clients also report feeling less stress when offering essential oils to their animals, even in the case of palliative treatments for terminal cases. I recently rescued a donkey from a kill pen situation, and the essential oils I selected for his care to help prevent flies on his horribly fly-bitten legs not only supported his physical healing, but also reduced his stress, helping him adjust emotionally to his new home by giving him feelings of grounding and peace. When I treat an animal with essential oils for his physical needs, emotional responses can occur in myself as well as the animal. There is a wealth of research on the ability of essential oils to relieve stress and anxiety.1,2,3,4,5 Just visit PubMed, do a search, and you will find a great many articles on essential oils. This is definitely an area with a strong base of scientific investigation and evidence.

While this is nowhere near all the essential oils available on the market today, it does represent a nice variety for you to start developing a relationship with. If these essential oils are part of a blend, you can still find their individual properties within. I would encourage you to smell each of the single essential oils. I often teach people to go outside, make contact with the earth, and take a few deep breaths. Then inhale the essential oil you have selected. If you cannot find the time or place to be outside, anywhere will truly work, even if you have to hide in the office bathroom!

When you inhale the essential oil, see how it makes you feel. I often close my eyes and inhale through each nostril, left and right, independently. Your brain will detect the essential oil differently through each side, and you may notice the oil will smell different. Think about how the oil makes you feel. Lighter? Free? Peaceful? It does not always matter what I or a book tells you a particular oil does. What matters is what the essential oil does for you, your self care and if you enjoy it.

Once you find several oils you enjoy, you can try your hand at blending a few. I often find that if several single essential oils are very pleasant to me, I may enjoy them even more within a blend. Most blends created for emotional purposes can be used at quite low concentrations — incorporating 1% to 3% of essential oils within a carrier oil such as fractionated coconut oil (also called MCTs or medium chain triglycerides).

Accessing essential oils during a busy workday

Here is of my favorite grounding exercises to do with essential oils. I often use a blend I initially created to calm my own dog. It primarily contains Roman Chamomile, German Chamomile, Frankincense and Ylang Ylang, diluted with fractionated coconut oil. I place several drops of this blend on the insides of my wrists. Then I place my wrists together, so they cross and touch with the essential oils in between them. I close my eyes, take several deep breaths, and visualize peace flowing throughout my body with each breath. The grounding that takes place is quite amazing. I have never had someone try this exercise who didn’t feel something quite profound.There are many options for accessing the supportive benefits of essential oils, even if you are in the workplace or have a “fragrance-free” philosophy. I am incredibly sensitive to artificial and chemical fragrances, and can even detect from several feet away when a person was riding in a car with a “smelly tree” air freshener. However when people are wearing properly-diluted natural essential oils, I do not experience headaches or recognize obnoxious odors.

  • Diffuser jewelry has become very popular. You can find bracelets, necklaces and even rings designed to let your apply your essential oil(s) of choice to an absorbent pad, a lava rock, or other natural material. You can then experience continual benefits from the low levels of oil that naturally evaporate off the jewelry; when feeling especially stressed or in need of a break, inhale deeply from the site of the essential oil application. Diffusion jewelry has become quite fashionable as well as discreet. Since many people naturally touch and play with a necklace or jewelry — you can easily administer a “stronger inhale” from your jewelry piece, even when in public.
  • Inhalers are another wonderful portable option. They emit a very low odor so others cannot detect it, and can be used “as needed” within the workplace and beyond. These inhalers are similar to nasal “sticks” sold as decongestants. The plastic tube (about the size of a lip balm) contains an absorbent wick on which the essential oils are placed. To use, uncap the tube, hold it to the nostrils and inhale deeply. This can be incredibly therapeutic, not only for stress and anxiety, but for physical needs as well. Allergies, sinus irritation, nasal drip and more can benefit from the use of an inhaler. If you want to be discreet about using an inhaler for workplace stress, remember that it’s becoming more commonplace for people to use inhalers during a respiratory illness. No one has to know you are treating your stress unless you choose to share the fact with them.
  • Don’t forget about diffusing essential oils into the air with a cool mist ultrasonic diffuser. There are many names and styles of diffuser on the market today — I wholly recommend the water-based diffusers, especially if they are to be used around animals. While there is much hype about essential oil diffusion being dangerous for animals, I can assure you from following thousands of patients that when the correct essential oils are selected, and water-based diffusion is used, essential oil diffusion can be incredibly helpful both physically and emotionally. I ran a diffuser in my surgical area, and found it greatly reduced my stress and anxiety when I encountered a challenging case. Over time, we also found the animals in my care awoke from anesthesia in a much calmer state. Animal facilities all over the world now safely diffuse essential oils for animals, staff and clientele.

Consistent use for compassionate self care

The benefits of essential oils for animal patients are as varied as your imagination allows. The hardest part of this equation is to actually use essential oils for our own self care. This is why diffuser jewelry and the use of essential oils with items like bathroom spray can provide important exposure for a person in need. It is far easier for me to dismiss the notion of a nice relaxing bath at the end of a hard day than it is to actually draw the bath. I encourage you to find several essential oils or blends you enjoy, and get creative in how you can easily and consistently expose yourself to their benefits. I am certain you will not be disappointed.

Essential oils for your emotional well-being

As a holistic modality, essential oils’ claim to fame is their ability to support physical well-being, while also possessing a natural chemistry that affects emotional balance.

The plant fragrances utilized in aromatherapy can have an uplifting impact on a veterinary practitioner’s depressed mood, or calm the frayed nerves and anxious attitudes that go with the daily highs and lows of being an animal care professional. An essential oil’s natural chemistry traverses the nasal passages and comes into immediate contact with the amygdala, the brain’s emotion and memory center.

Top oils that I utilize every day as a busy integrative practitioner are Copaifera reticulata (copaiba) oil, Citrus aurantifolia (lime) oil, Cedrus atlantica (cedarwood) bark oil, Vanilla planifolia (vanilla) absolute, Ocotea quixos (ocotea) oil, and Lavandula angustifolia (lavender) oil. The vanilla scent takes me back to peaceful childhood days of baking with my family. The oxygenating power of cedarwood opens my mind. Lavender makes me feel rested. Ocotea’s chemistry helps balance my blood sugar. The beta-caryophyllene in copaiba deals with my chronic inflammation. The lime contains all-important d-limonene and is refreshing and delicious!

Select a quality brand of essential oils with FDA-approved “internal use” labeling. The oils listed here can be combined and splashed into a glass of fresh ice water for impactful daily sipping! This blend can be applied topically as well. I love to use a roller bottle and apply these oils every day to the back of my neck or my wrists and forearms as a healthy, calming and balancing perfume. Use this blend and don’t forget that self care makes you a happier and more effective doctor!

References

1Zhang N, Yao L. “Anxiolytic Effect of Essential Oils and Their Constituents: A Review”. J Agric Food Chem. 2019 Jun 13;. doi: 10.1021/acs.jafc.9b00433. [Epub ahead of print] PubMed PMID: 31148444.

2Lowring LM. “Using therapeutic essential oils to support the management of anxiety”. J Am Assoc Nurse Pract. 2019 May 30;. doi: 10.1097/JXX.0000000000000227. [Epub ahead of print] PubMed PMID: 31169787.

3Sánchez-Vidaña DI, Po KK, Fung TK, Chow JK, Lau WK, So PK, Lau BW, Tsang HW. “Lavender essential oil ameliorates depression-like behavior and increases neurogenesis and dendritic complexity in rats”. Neurosci Lett. 2019 May 14;701:180-192. doi: 10.1016/j.neulet.2019.02.042. Epub 2019 Feb 28. PubMed PMID: 30825591.

4Al-Harrasi A, Csuk R, Khan A, Hussain J. “Distribution of the anti-inflammatory and anti-depressant compounds: Incensole and incensole acetate in genus Boswellia”. Phytochemistry. 2019 May;161:28-40. doi: 10.1016/j.phytochem.2019.01.007. Epub 2019 Feb 22. Review. PubMed PMID: 30802641.

5Hocayen PAS, Wendler E, Vecchia DD, Kanazawa LKS, Issy AC, Del Bel E, Andreatini R. “The nitrergic neurotransmission contributes to the anxiolytic-like effect of Citrus sinensis essential oil in animal models”. Phytother Res. 2019 Apr;33(4):901-909. doi: 10.1002/ptr.6281. Epub 2019 Feb 3. PubMed PMID: 30714232.

What millennials want from their vets

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A recent survey revealed key elements that millennials want in a veterinary visit, and how to ensure they remain loyal to a clinic.

Millennials might get a bad rap, but 75% have companion animals, and many make veterinary care a top priority. An independent survey released by Weave revealed what millennials want from their veterinary clinic experiences, what makes them move on from a clinic, and what helps them maintain loyalty. Here are some key findings:

92%of millennials are as concerned about their animals’ health as their own.

Only15%will always answer their phones even if they don’t know who’s calling, but 81% would definitely answer if they saw it was their veterinarians.

81%want their vets to automatically recognize them when they call; 72% say they have had to wait while their vets look up their accounts.

Millennials also like their veterinarians to be tech savvy. “They have grown up with technology, and expect that tech to enhance all experiences throughout their lives, including purchases like veterinary care for their animals,” says Brandon Rodman, CEO at Weave. “They require tailored services…. You can’t provide personalization without the right technology.” getweave.com

Mitochondria: the energy of life

The mitochondria is the powerhouse of the cell. But why is it unique and how can you protect the mitrochondria in small animals?

Mitochondria are fascinating and critically important “powerhouse” organelles inside cells. They use oxygen to make energy in the form of ATP. Mitochondria are unique in that their ancestors are bacteria that were ingested into cells to form a beneficial host/bacteria relationship (termed endosymbiosis) over 1.45 billion years ago. Thus, each of our cells has two different sets of DNA — one in the host cell nucleus, and the second in mitochondria (MtDNA). However, only maternal MtDNA is inherited.

During normal metabolism, mitochondria generate harmful reactive oxygen species (ROS) that must be neutralized and balanced by antioxidants to prevent cellular damage. In fact, mitochondria can inflict self-injury as they are the main intracellular generators of ROS as well as the main target of ROS attack. An imbalance of ROS and antioxidants can cause mitochondrial dysfunction, leading to inflammation and chronic illness. When antioxidant defenses are inadequate to neutralize ROS, cell damage and/or cell death results, initiating inflammation. Neutralization of ROS occurs by a variety of antioxidant systems, including the glutathione redox system, ascorbic acid, tocopherals, retinoids, catalase and superoxide dismutase.

Mitochondrial disease is a group of disorders characterized by dysfunctional energy production (ATP) along the mitochondrial electron transport chain. Most disease processes have some degree of mitochondrial dysfunction. Mitochondrial damage can occur from either too little or too much energy production. Because cells of the eye, brain and muscles require a lot of energy, they have particularly high densities of mitochondria. When mitochondria are not healthy, these tissues are often the first to show signs of poor function. Mitochondrial dysfunction can have primary (genetic) or secondary (e.g. age-related, infectious) causes. Aging tissues undergo oxidative stress because their mitochondria often fail to produce sufficient ATP. Since eyes are continually bombarded with oxidative stressors (UV light and oxygen), and mitochondria both generate and can be damaged by oxidative stress, it makes sense that chronic exposure to oxidative stress causes instability and cumulative damage of mitochondrial DNA.

Glaucoma causes chronic hypoperfusion of the optic nerve. Because the optic nerve contains abundant mitochondria, this makes it vulnerable to damage from glaucoma. Cancer is also associated with mitochondrial dysfunction. Mitochondria play important roles in carcinogenesis by altering energy metabolism, resisting apoptosis, increasing ROS production, and altering mtDNA. Uveal melanoma is the most common primary intraocular tumor in dogs, cats and humans. Novel therapies for this cancer are directed at inhibiting tumor-specific mitochondrial function, and hold promise as a new way to treat ocular cancers.

Supplements that reduce mitochondrial dysfunction help maintain healthy glutathione levels and include vitamins C and E (in the form of mixed tocopherals), alpha lipoic acid, coenzyme Q10, folate, vitamins B6 and B12, green tea extract, turmeric, Omega-3 fatty acids and zinc.

Providing a variety of antioxidants to dogs and cats may better protect the powerhouse of their cells from constant attack and self-combustion by ROS. The foundation of health is protection and enhancement of the energy of life.

Obesity linked to gene mutation

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The Morris Animal Foundation Golden Retriever Lifetime Study, is leading the pack with innovative research, and recently discovered genes linked to obesity.

You have probably seen more than your share of overweight canine patients. The Association for Pet Obesity Prevention estimates that 56% of dogs in the United States are overweight or obese — a huge problem for canine health.

Researchers at Cambridge University recently identified a gene mutation linked to obesity in Labrador retrievers; the same team plans to use DNA samples from dogs enrolled in the Morris Animal Foundation Golden Retriever Lifetime Study to search for a similar locus in this breed. Identifying dogs at risk for obesity can help you and your clients strategize on effective weight management. morrisanimalfoundation.org/golden-retriever-lifetime-study

Cryosurgery in the veterinary practice

Innovative advances in cryosurgery offer safe and effective treatment options with unlimited potential in the hands of the veterinarian.

Canine and feline dermatologic problems make up a substantial part of any small and/or mixed animal practice. Lesions ranging from small nodules to lumps and bumps are included in the daily questions clients ask practitioners during routine annual examinations and preanesthetic screenings of their animals. A large percentage of these masses can be benign proliferations of various gland tissues, or accumulations of abnormal but benign cell growths, while others are neoplastic tissues with invasive and metastatic potential. Traditionally, these masses have been excised with a scalpel and/or surgical laser, requiring the use of sedation or general anesthesia. While this has been an industry standard for many years, many patients presenting with skin lesions often have other problems, leading to safety concerns with chemical immobilization. Cryosurgery offers an attractive option for these patients, since it can be utilized with minimal or no sedation, collateral tissue damage and post-operative care.

Advances in cryosurgery

While cryosurgery is not a new modality, the tools used to deliver the required temperature change are evolving, making the target areas very precise. This enhanced precision reduces collateral tissue damage, leading to faster healing and less scarring. The capacity to achieve this precision is also what makes the biggest difference in treating smaller lesions. The specific unit I use in my practice is the CryoProbe X+, which runs at about -127°F. This specific model includes five separate tip sizes that can be used to match the lesion being treated, and can be operated with available 8g and 16g cartridges. (While treatment is often done without sedation or general anesthesia, the locations of some lesions will still require chemical immobilization to achieve desired results). Thanks to the precision of the micro-applicator tips, there is no collateral damage to healthy tissue, resulting in no discomfort to the patient. As such, treatments are very controlled and can be longer in duration if necessary. There is no required post-operative care; there is no bleeding, and sutures and cones are unnecessary, a wonderful benefit for both patients and caregivers. The following discussion identifies common lesions the author has treated with cryotherapy, but the modality’s use is certainly not limited to these.

  • Sebaceous adenomas: One of the most common skin ailments of aging and geriatric patients is the sebaceous adenoma. Also known as nodular sebaceous hyperplasia, this lesion is characterized as a benign non-haired soft tissue proliferation with an oily to crusted surface. The depth of abnormal tissue is often very superficial although the tissue can extend deep into the epidermis in some lesions. Cryosurgery is very effective for these, and one treatment is typically curative with very little follow-up required.
  • Cutaneous histiocytomas: Cryosurgery is very useful in the treatment of cutaneous histiocytomas. These benign and often solitary tumors often appear in places wheresurgical excision can be difficult. When they appear on the head, digits and ears, there is little room for excising while obtaining adequate margins without cosmetically affecting the closure. While these lesions can be deep and relatively dense, I have experienced successful outcomes with cryotherapy in completely resolving lesions as large as 1cm in diameter and ½cm in height. Larger masses may require an additional treatment or two to achieve complete resolution
  • Mast cell tumors: Mast cell tumors are often highly invasive and metastatic masses that can lead to very debilitating disease; higher grades and stages often result in diffuse systemic involvement. While cryosurgery is not my first line of choice in treating the masses that develop, it can be used as an additional modality to treat smaller nodules within the skin in areas where removal would be difficult. I have successfully treated smaller solitary Grade 1 nodules less than 1cm in diameter, with minimal to no recurrence. When treating these masses, I have found it beneficial to treat the nodule itself, along with 2mm to 4mm margins, and re-treating the same area after thawing has occurred.
  • Acral lick granulomas: Cryotherapy can also be used on chronic inflammatory lesions, such as acral lick granulomas, as an additional treatment modality. I have found it useful to intermittently freeze portions of the granulomas, along with using traditional therapies.
  • Epidermal and follicular inclusion cysts: These commonly-encountered nodular masses can respond well to cryosurgery. If possible, the author recommends either expressing or draining the lesions of any fluid or material prior to freezing with cryotherapy. This dramatically reduces the time required to freeze the area, permitting more effort to be directed at the tissue responsible for producing the material. If deep tissue nodules are being treated, or if draining of the lesions requires a scalpel or hypodermic needle, heavy sedation or general anesthesia is recommended for patient comfort.
  • Meibomian gland adenomas: For meibomian gland adenomas measuring 1mm or less, my preferred initial treatment option is cryosurgery over surgical excision. These common eyelid masses are full thickness proliferations often filled with a material that can be expressed with gentle pressure. I would suggest treating the tissue with cryotherapy from both palpebral and ocular sides to ensure all abnormal tissue is treated. There is little to no cosmetic change after healing.
    Photos courtesy of H&O Equipment, Inc., manufacturer of CryoProbe
  • Eosinophilic granuloma complex, ulcerative paradental stomatitis and oral neoplasia: Oral lesions such as eosinophilic granuloma complex, ulcerative paradental stomatitis and oral neoplasia that don’t involve bony tissue can be treated with cryotherapy when conventional medical and surgical techniques are not feasible. The lack of excess tissue for closure, despite efforts to elevate from the bone, can make it difficult to surgically close these lesions, leaving some cases to heal by second intention alone. I have used cryosurgery to debulk the main mass or lesions with promising results. I will reassess the areas on a regular basis and elect to refreeze the tissue as often as needed to suppress new growth formation.

Pre-treatment evaluation

Photos courtesy of H&O Equipment, Inc., manufacturer of CryoProbe

Prior to cryosurgery implementation, it is imperative that current standards of care be followed, with appropriate cytological and histopathological diagnostic steps performed as indicated. If a mass is deemed malignant with metastatic potential, addressing the mass with aggressive surgical intervention, radiation and chemotherapy would be indicated based on oncologist recommendations should the patient’s owner elect to pursue that line of treatment. Once a mass has been diagnosed, the use of cryosurgery can be employed for nearly any lesion on the skin, as well as some mucus membrane tissues.

Conclusion

Veterinary practices today are filled with innovative technological advancements that assist us in effectively treating patients in an ethical and compassionate manner. While traditional surgical and medical practices will always provide the foundation for our therapies, additional modalities such as cryosurgery also have their place.

By adding a cryosurgical unit to my treatment toolbox, I have been able to offer another option for commonly-seen dermatological lesions that is quick, effective, less invasive, and requires little to no anesthesia. Cryosurgery has been readily accepted by my clientele and well tolerated by my patients, making it a great fit for my practice.

 

 

 

 

Disclosure: The work expressed in this article is from Dr. Walrath’s direct clinical experience of using CryoProbe in his private practice since 2016. He is not a paid consultant or remunerated in any way.

KetoPet Sanctuary: ketosis, cancer and canines, part 3

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KetoPet Sanctuary has tested using a ketogenic diet as therapy in dogs with cancer. Part 3 looks at practical applications of ketosis for dogs at home.

KetoPet Sanctuary (KPS) has demonstrated the utility of a canine diet that induces a state of nutritional ketosis. When strictly adhered to and monitored, a ketogenic diet (KetoDiet) has been shown to increase the efficacy of standard of care and adjunctive treatments, thus prolonging survival and quality of life in canine cancer patients. While the stringently-controlled conditions at KPS cannot be replicated in a home environment, nutritional ketosis can be achieved and monitored by committed dog owners. In combination with integrative therapies, results that align with those at KPS can often be achieved.

Empowering the dog parent

Ketosis is a nutritionally-induced metabolic state in which the body preferentially uses ketone bodies as energy. Ketosis is achieved by fasting, caloric control, and/or control of macronutrient ratios (high fat/adequate protein/low carbohydrate). In the overwhelming fight for survival during cancer, diet is an accessible tool available to all pet owners. No one can fully control the cause or outcome, but dog parents can control what they put in their pets’ mouths, which can provide them with a sense of empowerment in the care of their canines.

Nutritional ketosis and chronic disease

Modern dogs are burdened with a variety of physiological and metabolic challenges due to the dramatic difference between the nutritive profiles of rendered, high glycemic-response kibbles and any possible, accessible nutrient profile found in nature.1 High-heat processed feeds (kibble and canned) are contaminated with heavy metals,2 excessive levels of minerals,3,4 fat soluble vitamins,5 anti-nutrients,6 carbohydrate levels that inhibit ketosis,7 advanced glycation end products (AGEs)8 and pathogens.9 A shift to fresh low-carbohydrate food decreases exposure to these toxins and metabolically-damaging macronutrient ratios.

With and without additional therapies, nutritional ketosis has resulted in recovery from chronic skin issues, ear infections, odors (mouth and stool), chronic pancreatitis/hyperlipidemia, ocular discharge, chronic bladder stones, UTIs, obesity, arthritis and food allergies (as confirmed with allergy testing), as well as increased energy and mobility.

 

Dr. Barbara Royal reports an 80% success rate in many of these conditions. However, treatment plans that depend solely on a metabolic component have not been found to be significantly successful in the treatment of cancer. Rather, ketosis has been shown to improve the efficacy of standard of care and integrative oncology therapies while also providing protective benefits to healthy cells.

Dr. Royal has experienced resolution of recurring mast cell skin tumors, hemangiosarcomas, bladder cancers and osteosarcomas in cancer patients that have dramatically exceeded their expected expiration dates, as well as shrinking and stabilizing of lymphoma (perhaps the most notably responsive cancer at KPS) with nearly two years of no progression when chemo wasn’t tolerated. She has also experienced resolution of severe vaccine-induced intractable seizures (uncontrolled by general practice, critical care and neurology veterinarians) after implementing a KetoDiet.

Discussion

When properly executed and monitored, inducing metabolic ketosis and applying adjunctive integrative therapies with standard of care treatments can result in increased longevity and quality of life when compared to standard of care alone. The positive clinical responses veterinarians have seen, and the intriguing research on ketogenic diets for cancer in human literature, warrant additional investigation into this non-toxic and relatively inexpensive holistic therapy for canine cancer patients. In addition, open-minded veterinarians are trying other adjuvant metabolic therapies (see sidebar). If you are seeking to incorporate integrative therapies with the metabolic component of nutritional ketosis into your treatment plan, these are the tools to research and consider.

Ultimately, the most important factors for success are knowledge, effort and compliance. As with us, the health of our canine companions can be transformed by the food they are fed. The transition from cereal (kibble) or canned diets to fresh feeding (a KetoDiet) can initially seem daunting. In short order, however, it will become habit and seem simple. The KetoDiet can improve a dog’s health on its own, or in conjunction with other therapies, in the treatment of cancer, making the benefits wide-ranging and priceless. Additional resources on how to implement a KetoDiet for canines can be found in Parts 1 and Part 2 of this article, the KetoPet website, and the KetoPet Group and Ketogenic Dog Group on Facebook.29, 30

The authors want to acknowledge the veterinarians, dog parents and advocates who have shared the benefits of KetoDiets for many disease states. To the dog parents of our cases, thank you for sharing your stories.

References

1Bosch E, Plantinga E, Hendriks, W. “Dietary Nutrient Profiles of Wild Wolves: Insights for Optimal Dog Nutrition”. Researchgate.net, Nov. 2017.

2“Heavy Metal Regulation and Results”, KnowYourPetFood.org

3“Development of AAFCO Mineral Tolerances”.  AAFCO

4“Mineral Results”. KnowYourPetFood.org.

5“Animal & Veterinary, Resources for You, Animal Health Literacy, Vitamin D Toxicity in Dogs”. FDA.gov.

6“Phytic Acid and Results, KnowYourPetFood.org.

7“Masood W. “Ketoigenic Diet”. ncbi.nlm.nih.gov.

8Becker, K. “High Heat Processing Creates Higher Levels of Advanced Glycation End Products”. HealthyPets.Mercola.com

9“Pathogen in dry kibbles – CDC Salmonella Outbreaks, 2007, 2012”. Dry Kibble, Diamond. 2008, Mars PetCare Morbidity&Mortality Weekly.

10McLelland J. “How to Starve Cancer”. howtostarvecancer.com.

11“Mistletoe: The Holiday Plant is Making headlines as Alternative Cancer Treatment”. EuroMedFoundation.com.

12“Enhancing anticancer effects, decreasing risks and solving practical problems facing 3-bromopyruvate in clinical oncology: 10 years of research experience”. ncbi.nlm.nih.gov.

13“Metformin and cancer: an existing drug for cancer prevention and therapy”. ncbi.nlm.nih.gov.

14“Statin use and Cancer risk: a comprehensive review”. ncbi.nlm.nih.gov.

15“Vitamin C and Doxycycline: A synthetic lethal combination therapy targeting metabolic flexibility in cancer stem cells (CSCs)”. ncbi.nlm.nih.gov.

16“Repurposing drugs in Oncology (ReDO) – Mebendazole as an anti-cancer agent”. ncbi.nlm.nih.gov.

17“Dichloroacetate (DCA) as a potential metabolic-targeting therapy for cancer”. ncbi.nlm.nih.gov.

18“Dose evaluation safety study in individuals with astrocytoma taking PolyMVA and PolyMVAsurvivors.com”. ClinicalTrials.gov.

19“COX-2 inhibitors in cancer treatment and prevention, a recent development”. ncbi.nlm.nih.gov.

20“Effects of resveratrol, curcumin, berberine and other nutraceuticals on aging, cancer development, cancer stem cells and microRNAs”. ncbi.nlm.nih.gov.

21“Medicinal Mushrooms (PDQ)”. ncbi.nlm.nih.gov.

22“Yunnan Baiyao for Dogs: Chinese Herb for Bleeding Dog Cancers”. DogCancerBlog.com.

23“Epigallocatechin Gallate (EGCG) is the most effective cancer chemopreventative polyphenol in green tea”. ncbi.nlm.nih.gov.

24“Artemisinin and its synthetic derivatives as a possible therapy for cancer”. ncbi.nlm.nih.gov.

25“The current state and future perspective of cannabinoids in cancer biology”. ncbi.nlm.nih.gov.

26“Hyperbaric oxygen therapy and cancer – a review, and Hyperbaric oxygen therapy as adjunctive strategy in treatment of glioblastoma multiforme”. ncbi.nlm.nih.gov.

27“Anticancer effects of high-dose ascorbate on canine melanoma cell lines, and Intravenous Vitamin C for Cancer Therapy – identifying the current gaps in knowledge”. ncbi.nlm.nih.gov.

28“State of the Art Laser Surgery”. aesculight.com.

29Resources, Read Our eBook (free download), KetoPetSanctuary.com.

30Resources, Create a Ketogenic Diet (free calculator), KetoPetSanctuary.com.

Equine metabolic syndrome

Cases of equine metabolic syndrome (EMS) are on the rise, and research sponsored by Morris Animal Foundation is helping to unravel the complexities of EMS.

The term “equine metabolic syndrome” was coined in 2002. It was used to describe a disease that shared many features with metabolic syndrome in people. In horses, the syndrome is characterized by obesity (either generalized or regional), insulin resistance and a predisposition to laminitis.

The rise in EMS cases coincided with the transition of horses from working animals to companion animals with more sedentary lifestyles. But EMS is a complex disease that involves more than just lifestyle, and has both genetic and environmental components. This complexity has complicated EMS research, though new breakthroughs could provide key clues toward treating this disease.

Morris Animal Foundation is a major sponsor of EMS research around the world, and our grantees are leaders in the field. We’re excited about some recent findings from our funded grants.

Genetics play a role in EMS

A genetic explanation for this disease makes evolutionary sense and supports what we see clinically. It was beneficial for early equids to develop an efficient metabolism to survive in times of scarce resources. However, this same trend toward thriftiness can lead to obesity and insulin dysregulation.

Researchers at the University of Minnesota published findings on a correlation between height in Welsh ponies and their baseline insulin levels. They found that shorter ponies had higher baseline levels, which translates into a greater potential for EMS. 1

Data on the predisposition of certain horse breeds for developing EMS provides further evidence for a significant genetic influence. The Minnesota team also published a study that estimated the heritability of certain EMS biochemical traits in Morgan and Welsh ponies, which ranged from moderate to high heritability. The findings have implications for future research on genetic risk factors for EMS.2

And so does the environment

The University of Minnesota research team is also investigating environmental factors. Although it’s tempting to give genetics the major role in the development of EMS, some experts suggest that almost 50% of the phenotypic variability in EMS is due to environmental factors.

The Minnesota team recently reported how endocrine-disrupting chemicals could play a role in clinical disease in horses. They reported that horses living close to federal Superfund sites, where endocrine-disrupting chemicals may be concentrated, were more likely to have a history of laminitis and biochemical abnormalities related to EMS.3 Diet, exercise and season can also influence the EMS phenotype, but research has shown that these factors account for only a small part of this variation.

New research focus areas

Morris Animal Foundation has several new studies in progress that are tackling EMS from different directions.
Recently funded projects include:

  • How the gut microbiome and metabolome influence insulin levels
  • A description of the microbiome in Shetland ponies who do and don’t develop EMS
  • The effect of phenylbutazone on insulin and glucose dynamics
  • The roles of adiponectin and systemic inflammation on insulin dysregulation.

EMS is a complex disease. Through strategic funding, Morris Animal Foundation hopes to generate a path to better diagnostics, treatments and, hopefully, new
preventive strategies for this serious threat to horses. Learn more at morrisanimalfoundation.org.

References

1Norton EM, Avila F, Schultz NE, Mickelson JR, Geor RJ, McCue ME. “Evaluation of an HMGA2 variant for pleiotropic effects on height and metabolic traits in ponies”. J Vet Intern Med. 2019;1–11. https://doi.o r g /10 .1111/ j v i m .15 4 03

2Norton EM, Schultz NE, Rendahl AK, McFarlane D, Geor RJ, Mickelson JR, McCue ME. “Heritability of metabolic traits associated with equine metabolic syndrome in Welsh ponies and Morgan horses”. Equine Vet J. 2019;475-480. h t t p s : //d o i . o r g /10 .1111/e v j .13 0 53

3Durward-Akhurst SA, Schultz NE, Norton EM, Rendahl AK, Besselink H, Behnisch PA, Brouwer A, Geor RJ, Mickelson JR, McCue ME. “Associations between endocrine disrupting chemicals and equine metabolic syndrome phenotypes”. Chemosphere. 2019;652-661. https://doi.org/10.1016/j.c h e m o s p h e re. 2 018 .11.13 6

Do cats with chronic kidney disease need gastric acid suppression?

Gastrointestinal protectant use is ubiquitous in veterinary medicine. But is it always necessary? Learn more about new concepts regarding the use of gastric acid suppression in cats with chronic kidney disease.

It is a rare geriatric cat that doesn’t have some decline in renal function. Administration of gastric acid suppression has been considered an important component of treatment for chronic kidney disease. However, newer veterinary studies are calling this practice into question.

Chronic kidney disease (CKD) is one of the most common problems affecting older cats, with some estimates suggesting the disease affects at least 50% of older cats (defined as cats over 10 years of age). Other experts put the number even higher, at nearly 80% in cats over 15 years of age.

A lot of owners and veterinarians struggle to treat this complex illness. Although we’ve made great advances in helping cats with CKD live longer with a better quality of life, achieving this can require medication, diet change and fluid support. The multitude of treatments can be tough for cat owners to manage, which in turn can lead to poor compliance. Knowing which treatments are supported with strong evidence is key to a successful outcome.

In people, it’s long been recognized that chronic kidney disease can lead to gastric ulceration. However, gastric ulceration has never been firmly demonstrated in cats with CKD.

“There is a lot of dogma in veterinary medicine that comes from human medicine,” said Dr. Katie Tolbert, a Morris Animal Foundation-funded researcher and Associate Professor at Texas A&M University, in a recent interview. “We’re taught that CKD causes stomach ulcers in cats – it’s something that’s been passed down. However, when I talk to pathologists, they tell me they hardly ever see ulcers in cats with CKD.”

Dr. Tolbert took to heart what she heard from her pathology colleagues and studied acid secretion in cats with CKD and cats without the disease. She looked at a number of parameters including gastric pH and serum gastrin levels and found no differences between the two groups for either value. Dr. Tolbert concluded that, based on these results, cats with CKD might not need acid suppression. She published her results in the Journal of Veterinary Internal Medicine.

In her current Morris Animal Foundation-funded project, Dr. Tolbert is taking this observation one step further. She’s running a clinical trial where cats with CKD get omeprazole and others get a placebo for two weeks. After a two-week rest period, the groups switch. The research team is blinded to the treatment each cat is receiving. They’re collecting observational data as well on everything from activity to frequency of vomiting, since acid suppression is often given to improve appetite and decrease nausea and vomiting. Dr. Tolbert hopes that her results can add to the conversation around the use of these medications in cats with CKD.

Although gastrointestinal protectants have a wide margin of safety, they’re not without side effects. Mounting evidence demonstrates that the use of proton pump inhibitors (PPI) causes disruptions of the gut microbiome and, in people, there is a link between PPI use and an increased risk of Clostridium difficile infections. A recent paper looking at gut microbiome changes in healthy cats given omeprazole did not demonstrate dramatic changes after 60 days of use. While encouraging, these results might be different in cats with underlying disease or in cats that are given acid suppressors for even longer periods of time which is common in cats with CKD.

In addition to potential changes in the microbiome, long-term use of proton pump inhibitors can lead to gastric mucosal hypertrophy. There also is a rebound gastric acid hypersecretion that can occur after gastric acid suppression therapy is discontinued.

To provide greater clarity on when to use or not use acid suppressants and other similar medications, the American College of Veterinary Internal Medicine released a consensus statement in 2018 on the rational use of gastrointestinal protectants. The statement covers a number of clinical scenarios including renal disease in cats. The opinion of the panel was that cats with CKD should not receive prophylactic gastroprotectants if they are in International Renal Interest Society (IRIS) stages 1–3. They felt that additional studies are needed to determine if acid suppression is helpful for individuals in IRIS stage 4 renal disease.

Given the growing body of evidence that casts doubt on the routine use of gastric acid suppression in cats with CKD, withholding this medication in a cat with early stage CKD is reasonable. This especially holds true when other treatments, such as diet change, are available as a first step. If gastric acid suppression is instituted in a decompensated patient, weaning the patient off this medication when stable also is a reasonable alternative to long-term therapy.

To learn more about cats with chronic kidney disease and gastric acid suppression, listen to Morris Animal Foundation’s podcast with Dr. Tolbert discussing her studies on the control of gastric acid secretion in both dogs and cats.

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